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 NCPAD Monographs
National Center on Physical Activity & Disability (NCPAD)
   An Eden Alternative: A Life Worth Living

The Eden Alternative™ -- Renewing Life in Nursing Homes

As the U.S. population ages, many of us will become consumers of long term care. We may need to put our parents in residential settings, or to find assisted living for ourselves. Luckily, a new philosophy is sweeping the nation's nursing homes, one that offers a "life worth living" inside long term care. It's called the Eden Alternative.

One of a handful of pioneering approaches to reforming the long term care industry, the Eden Alternative was created in 1991. Dr. William H. Thomas, his wife Judy Meyers Thomas and the administrative team at Chase Memorial Nursing Home in upstate New York sought a new paradigm of care for the residents of the rural nursing home. They found inspiration in nature. As Dr. Thomas wrote, the vision went something like this: "We'll bring in 100 birds, two dogs, four cats, three rabbits and a flock of laying hens…Then we'll plow the lawn and start a large organic vegetable garden outside our residents' windows."

Many nursing homes would have farmed this vision out to a committee, but not Chase. One day, the birds arrived--all 100 of them! The result was pandemonium. From that day, the definition of long term care was changed forever. Did it happen easily? No. Several staff members could not accept or adapt to change, and left. Others complained. Some of the loudest voices were residents who didn't want pets! But the birds went to work, and the naysayers became the greatest advocates of a "new way."

The results of this vision were significant. At Chase Memorial, during the implementation of the Eden Alternative, research showed a reduction in a) overall number of drug prescriptions, b) infection rates, c) staff turnover, and d) the mortality rate. Savings on drug prescriptions were allocated to maintaining the Eden environment. Studies of the Texas Eden Alternative Project at several nursing homes charted significant decreases in a) in-house pressure sores, b) PRN (anxiolytic and antidepressant) medications, and c) staff absenteeism. Finally, the best indicator of success is census count. Eden Alternative homes across the nation report waiting lists for their beds.

A Day in an Eden Alternative Home

You notice something different about an Eden home before you enter the door. It might be a winding garden path, an attractive landscape, or playground equipment in the front yard. You may see birds at a feeder or hear a donkey braying, even in an urban neighborhood!

This is a photo of Chicquita the Conure.
Chicquita the Conure "gives a kiss."
When you enter the building, something else catches your senses-the tantalizing aroma of a good meal. You may hear the conversation of children, watch the flight of finches in an aviary, or revel in the richness of lush house plants, paintings, pictures, photographs and schoolwork on the walls. Everything reminds you of home.

Many residents awaken to the sound of birdsong, because there are parakeets in nearly every room. Every day, the "birdmobile" (a converted medication cart) makes the rounds of rooms, with food and supplies. At Chase Memorial, the birdmobile is manned by volunteers from a local middle school. The kids enjoy interacting with the birds and their owners.

This is a photo of an Eden resident with children and pets in an Eden home.
Children and pets are naturals in an Eden Home.
Once awake, a person might choose to have a cup of coffee, or tea. Or they might decide to have breakfast in the dining room. Many Eden Alternative homes have open hours for dining. The homes may offer a buffet, so residents have a choice of when and what they eat. In the Eden Alternative home, the activities schedule has been altered to reflect the natural rhythms of home life. Rather than hunting for residents for the programmed activities, the activity department staff are helping residents care for the tame rabbits and hedgehogs, the cats and guinea pigs. You can imagine the excitement when the hamster has babies.

Residents may decide to walk or pet the dogs, or to visit with the children in the on-site child care center. At lunch, they sit with their friends. They may enjoy tomatoes harvested from the nursing home's gardens. They may decide to take a nap, join a group of friends for a game of cards, or work in the garden for a while.

The Garden of Eden

The gardens are designed for accessibility. As Dr. Thomas writes, "Elderly residents cannot and should not have to climb over misplaced obstacles or reach into a flower or vegetable bed that's too wide." Walks are paved for wheelchairs. Raised beds, benches and shade are all important components of the garden. The most crucial aspect of the Eden Alternative garden, however, should never be overlooked: it must be inviting and available-not a showplace, not a well-trimmed yard, but a natural retreat for everyone at the nursing home. It should never be "off limits." Many Eden homes combine gardens and playgrounds, so that residents may watch the children at play. A well-equipped playground encourages visitors. Before you know it, families are bringing their young ones to see grandma.

The Zachary Test

If you are looking for a nursing home, give it the Zachary Test. One day Dr. Thomas took his son Zachary to visit a nursing home. On the way, he writes in Life Worth Living, "the conversation went something like this:

    Zach: When we get there I'm going to play with the kids.
    Dad: They don't have any kids there, Zach.
    Zach: Well, I'll play with the dogs then.
    Dad: They don't have any dogs.
    Zach: But I can help feed the birds, right?
    Dad: Sorry, they don't have any birds.
    Zach: I'll play with the people (residents). That will be fun.
    Dad: Maybe…we'll see.
    Zach (in a disappointed voice): Dad I thought we were going to a nursing home.

Making It Happen-The First Step

The very first step in creating an Eden Alternative environment starts with the resident. It's similar to "person-centered planning," where all care considerations focus on the needs of the resident-a far cry from the status quo.

What is it about nursing homes that is so disturbing? Dr. Thomas writes that nursing homes are built on a medical model of care, much like hospitals. Staff are arranged in a hierarchy with administrators, doctors and nurses at the top and nursing assistants-the people who actually care for residents-at the bottom. The Eden Alternative replaces the medical model with a "human habitat" giving real responsibility to the people who spend the most time with residents.

This is a photo of a toddler hoop gracing an Eden garden.
Toddler hoops grace an Eden garden.
You could argue that our greatest fear is to leave our homes and go to a place where we will receive intimate nursing care from strangers. How do you assuage this fear? To build relationships (the cornerstone of care), the Eden Alternative home has permanent nursing care teams. Each team is responsible for a small number of residents, as well as the operation of their work units. For instance, in an Eden Alternative home, the certified nurse assistants (CNAs) prepare their own schedules and daily assignments. Changing this single aspect of nursing care-creating permanent care teams-has produced a reward: staff turnover is reduced, and the staff members and residents are much happier.

Jeanette Reisinger, RN, a team coordinator at Good Shepherd Care Center in Versailles, MO, says that continuity of care helps nursing assistants and residents become "like a family." Good Shepherd incorporates the Eden Alternative into new employee orientation and ongoing weekly team meetings. Nursing staff are not assigned to units; they must "apply" and be accepted for the team of their choice.

An Eden team includes everyone who comes into contact with the residents-the housekeepers, activity, laundry, maintenance and rehab staff. Staff members quickly learn to make decisions based on the residents' needs, and to work cooperatively for that end. Teams elect their own leaders; usually the administrator, Eden Coordinator or nurses act as consultants to the permanent care teams.

Three Plagues of Nursing Homes

Dr. Thomas write that people in nursing homes face a prevalent disease. Heart disease? Diabetes? Parkinson's or Alzheimer's? Ironically, this is a disease of the heart, with three important symptoms: loneliness, helplessness and boredom. Let's see how the Eden Alternative environment combats these "plagues."

Loneliness

The cure for loneliness is companionship. That's where the birds come in. As pets, parakeets are lively, responsive and bond with their owners. At Chase Memorial, those who didn't want a parakeet soon changed their minds.

Dogs and cats are important members of the Eden Alternative home. We all know that there are dog people and there are cat people-why should we leave that aside when we move to assisted care? Eden homes report that people respond warmly, and sometimes surprisingly, to cats and dogs. Pets get people talking, and involved in their environment. The stories are legend: how a man who hadn't uttered a word in months said, "Nice doggie." How a woman with dementia "adopted" the birdmobile and quit wandering. How another woman, who had partial paralysis, moved her hand to stroke a cat.

In the United States, two highly segregated populations are children and elders. Children are sent off to schools with their peers. Elders are sent to nursing homes full of their peers. The Eden Alternative home strives to keep the family together. What better way than to offer on-site child care to staff members? And to include children of all ages in the daily lives of residents? Sharing stories, playing games, helping with homework, working together in the garden, holding a baby- all are simple ways to bring generations together.

Helplessness

By helping children, and caring for pets and plants, elders overcome feelings of helplessness. They are, in a real way, giving care when they make decisions about their environment and the people around them.

Boredom

Finally, a home that opens its doors to pets, children and the community has little room for boredom. What happens when the cat goes after the cockatiel? When the dog chases a rabbit across the garden? When a finch flies out of the aviary? The unexpected! Life in an Eden home is spontaneous. The team on Unit 3 may decide to cook spaghetti for dinner. Or the Blue team is having a garage sale. The folks in the Rose Arbor are going out for a show. Or residents at West Hall are mixing up cucumber pickles. The kids have a day off school and the home is full of young volunteers.

A final note-you would not expect conformity in an Eden home, either. How do you tell the difference between residents' rooms? Well, they've brought their own furniture, their favorite artwork and photographs. The rooms are painted in their favorite colors, and they decide how to decorate the halls. Each Eden home is different, as Johanne Buck, Activities Coordinator at Spruce Lodge, "shares a defining moment. It was the moment when, she says, she knew it was really a home in the best traditional sense of the word. 'I came walking into the living room, and there was a resident asleep on the couch, one arm draped over the side, her fingers resting on the head of our daily visitor Max, a gentle golden mutt, who was also happily snoozing away."
(from www.edenmidwest.com)

Eden Alternative Principles

An "Edenizing" home adopts "Ten Principles." These include: "surrendering the institutional point of view" and adopting the "human habitat model that makes pets, plants and children the pivots for daily life in a nursing home." An Eden home "provides easy access to companionship," "provides opportunities to give as well as to receive care," and "imbues daily life with variety and spontaneity." Moreover, the Eden Alternative home replaces programmed activities with natural activities of daily life.

This is a photo of young volunteers bringing smiles to Eden residents.
Young volunteers bring smiles.
Getting There

How does a nursing home become an Eden Alternative home? Today, certification assures that the residents, owners, administrators, families and staff are committed to the Eden Alternative. The administrator and other staff members are trained as Eden Associates, and receive ongoing advice. Each step of the process-and it is a process, not a marketing ploy-is acknowledged. In an Eden Alternative home, "change is good." The Eden community supports every effort by forming regional coalitions, and stays in close contact through discussion groups on the Eden web site.

Eden Alternative Resources
Eden Alternative
742 Turnpike Road
Sherburne, NY 13460.
Phone: 607-674-5232
www.edenalt.com
www.edenmidwest.com

Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home by William H. Thomas, M.D. VanderWyk & Burnam. 1996. Available at bookstores.

Learning from Hannah. 1999. Available from Eden Alternative Online Store.

The Eden Journal. Quarterly. Available from Eden Alternative Online Store.

The Able Gardener: Overcoming Barriers of Age and Physical Limitations by Kathleen Yeomans. Good Earth Publications, Columbus, NC.

About this Article
This article was edited for the National Center on Physical Activity and Disability, a collaborative project of the National Center on Accessibility, the University of Illinois at Chicago and the Rehabilitation Institute of Chicago. NCPAD is headquartered at the Department of Disability and Human Development, University of Illinois at Chicago,1640 West Roosevelt Road, Chicago, IL 60608-6904. NCPAD is funded by the Secondary Conditions Prevention Branch, Office on Disability and Health, Centers for Disease Control and Prevention. www.ncpad.org




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